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Pulmonary & Critical Care

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What are the diagnostic criteria of ARDS?

  • Symptoms onset within 1 week of clinical insult or new/worsening symptoms within past 1 week

  • Bilateral opacities on lung imaging (not explained by pleural effusion, pulmonary nodules, etc.)

  • PaO2/FiO2 <300 (mild= 200-300, moderate= 100-200, severe= <100)

 

What are the mainstays of ventilator management in ARDS?

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How do you treat each of the asthma categories?

  • Intermittent- SABA

  • Mild persistent- low-dose ICS and SABA PRN or low-dose ICS plus SABA together as needed

  • Moderate persistent- combination low-dose ICS-formoterol and 1-2 inhalations PRN up to 12 inhalations/day or medium-dose ICS and SABA PRN or low-dose ICS-LABA daily

  • Severe persistent- combination medium dose ICS-formoterol daily and 1-2 inhalations PRN up to 12 inhalations/day (preferred option) or medium-dose ICS-LABA daily or medium-dose ICS plus LAMA daily and SABA PRN

 

What asthma medication is associated with mental health changes/depression? 

  • Montelukast

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How do you define bronchiectasis? What are classic findings of bronchiectasis on CT?

  • Irreversible enlargement of airways

  • Thickened bronchial walls or cysts, airways that do not taper distally

 

How does bronchiectasis present?

  • Chronic cough with no prior smoking hx, clubbing, frequent respiratory infections, sputum with pseudomonas or aspergillus

 

What conditions may you want to test for if you note bronchiectasis?

  • Cystic fibrosis, ciliary dysfunction (Karteneger’s dz), a1-antitrypsin deficiency

 

Treatment of bronchiectasis?

  • Clear airway with bronchodilators, inhaled glucocorticoids, some studies recommend long-term macrolide antibiotics

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What are the GOLD criteria parameters?

  • Symptoms (mMRC or CAT score) and exacerbation history (with and without hospitalizations)

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Mainstay of treatment of acute exacerbation? 

  • Steroids → decrease need for hospitalization, LOS

 

When do you use antibiotics in COPD exacerbation?

  • Moderate to severe COPD exacerbation (≥2 of 3 cardinal symptoms: increased dyspnea, increased sputum volume/viscosity, or increased sputum purulence)

  • Or COPD exacerbation requiring hospitalization and/or ventilatory support (either invasive or noninvasive)

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What antibiotics for COPD exacerbation if indicated?

  • No risk factors for pseudomonas, give Azithromycin or 2nd/3rd generation cephalosporin

  • (+) risk factors for pseudomonas, give ciprofloxacin

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When to offer home O2?

  •  O2 sat less than 88% or PaO2 on ABG less than or equal to 55 (threshold is 59 if pt has concomitant CHF, cor pulmonale, erythrocytosis)

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What are the hallmarks of the following DPLDs?

  • IPF (idiopathic pulmonary fibrosis) - Chronic - months, insidious, age >50, +/- clubbing, honeycombing on imaging; diagnosis of exclusion

  • COP (cryptogenic organizing pneumonia) - Subacute with cough/fever/malaise 6-8 weeks, patchy opacities that look like PNA

  • NSIP (nonspecific interstitial pneumonia) - younger population, usually associated with autoimmune disorders, lower-lobe reticular changes and GGOs, rare honeycombing

 

What is the most common DPLD? 

  • IPF

 

Work-up for a DPLD? 

  • Complete PFTs, DLCO measurement, high-resolution CT, CRP, ESR, ANA, RF, myositis panel, anti-CCP

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What should you assess for a patient with hypoxia?

  • Determine O2 needs

  • Assess work of breathing (rule out ventilation issue) → Get ABG

  • Physical exam and CXR → Assess for trachea midline, stridor, crackles, wheezing, decreased BS, JVP

  • Differential should include: cardiogenic or non- cardiogenic ARDS flash pulm edema, aspiration or new PNA, mucus plug, PE, PTX, anaphylaxis, alveolar hemorrhage, COVID

 

How do you manage acute hypoxia?

  • Give supplemental O2 (goal >92%) via the following modalities NC > NRB > HFNC > > HHFNC > BiPAP

  • If issue with volume/flash pulmonary edema → IV lasix, BiPAP, consider nitro gtt

  • If new PNA → broad-spectrum antibiotics

  • If COVID → steroids

  • If c/f aspiration → suctioning, upright positioning, NPO

  • If c/f mucus plugging → suctioning, chest PT, involve pulm for possible bronchoscopy

  • If clear lungs, true hypoxia, tachycardia → suspect PE → heparin gtt and CTA, if stable

 

EKG finding often associated with hypoxia + pulmonary disease? 

  • MAT

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What is an incentive spirometer?

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How do you define obstructive sleep apnea?

  • Sleep interruption due to repetitive upper airway narrowing or collapse

  • On polysomnography will see diminished airflow despite muscular activity of rib cage and abdomen as an effort is made to breathe against airway occlusion

 

How do you diagnose obesity hypoventilation syndrome? 

  • Daytime hypercapnia with CO2 >45 mmHg; commonly associated with CHF, pHTN, erythrocytosis, volume overload

 

Treatment for obesity hypoventilation syndrome? 

  • Weight loss, CPAP (if coexisting OSA) or BiPAP (if sleep-related hypoventilation)

 

What is the Gold standard of diagnosis of obstructive sleep apnea?

  • In-laboratory polysomnography

 

What is the diagnostic criteria of obstructive sleep apnea?

  • 5 or more predominantly obstructive events per hour of sleep PLUS at least of the following: sleepy/fatigued/insomnia, waking up SOB/choking, snoring, and/or comorbidity including HTN/mood disorder/CAD/stroke/CHF/afib/T2DM

  • OR 15 or more predominantly obstructive events per hour of sleep

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What is Light’s criteria?

  • A method used to determine whether a pleural effusion is exudative or transudative. 

  • Satisfying any ONE criterium means it is exudative: 

    • Pleural Total Protein/Serum Total Protein ratio > 0.5. 

    • Pleural lactate dehydrogenase/Serum lactate dehydrogenase ratio > 0.6

    • Pleural fluid LDH >⅔ than the upper limit of normal serum LDH

  • https://twitter.com/Paul_Wischmeyer/status/1600834269223747590

 

What is the difference between transudative and exudative effusions

  • Transudative effusions have low protein and typically a result of:

    • CHF

    • Hypoproteinemia/Hypoalbuminemia (Nephrotic syndromes, liver cirrhosis)

  • Exudative effusions have high amounts of protein and typically a result of:

    • Hemothorax

    • Pulmonary embolus

    • Neoplastic (Lung CA)

    • Inflammatory disorders (RA, SLE)

    • Infectious (empyema)

    • Chylothorax

 

What is a parapneumonic effusion? 

  • Pleural effusion associated with a bacterial infection

 

What is a complicated parapneumonic effusion (empyema)? 

  • Complicated means that it is loculated or infected aka bacteria has invaded the pleural space

  • Uncomplicated = sterile and free flowing

 

How do you distinguish a complicated parapneumonic effusion from an uncomplicated one?

  • Pleural fluid pH < 7.2 or microorganisms on gram stain 

 

What are the most common bacteria associated with community-acquired empyema? 

  • Strep pneumo, Strep pyogenes, Staph aureus

 

What are the most common bacteria associated with hospital-acquired empyema? 

  • MRSA, enterobacter

 

What is the treatment for an empyema? 

  • Drainage via VATS or chest tube with fibrinolytic

 

What might you suspect in a patient with malignancy and pleural effusions + hilar lymphadenopathy? 

  • Lymphangitic carcinomatosis  = tumor presence in pulmonary lymphatics

 

What is a chylothorax? 

  • Pleural effusion with TG level >110, usually lymphocytic predominance

 

What are the most common causes of chylothorax? 

  • Non-traumatic = malignancy -> lymphoma, traumatic = thoracic surgery

 

How does PEEP (via invasive or noninvasive ventilation) help with pulmonary edema? 

  • decreases preload and afterload 

  • moves fluid from intraalveolar to extra alveolar space which decreases A-a gradient 

  • increases lung volumes which decreases atelectasis

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What are the signs of a DVT on ultrasound?

  • Non-compressible venous segment → sufficient for dx (you do not need to see clot)

  • Anechoic (dark) appearance of thrombus when you do compress

 

How can you classify a PE?

 

How do you manage a PE?

  • Use PESI score to determine clinical severity and need for admission

  • Shock or hypotension → Consider TPA vs surgical embolectomy or flowtriever

  • IVC filter recommended in acute proximal DVT or acute PE with contraindication to AC

  • Anticoagulation to stabilize clot and prevent further events → enoxaparin or DOAC

  • If provoked → 3-6 months of AC, if idiopathic or malignancy-related → lifelong AC, unclear → consider hypercoagulability work-up and consider extending AC with reduced dose apixaban https://www.nejm.org/doi/full/10.1056/nejmoa1207541

  • Pts with confirmed PE do not require routine duplex imaging of lower extremities

  • PE: https://twitter.com/ApoThera/status/1611301578140680195

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